District Name Public Schools

STONINGTON PUBLIC SCHOOLS

NOTICE AND CONSENT TO CONDUCT AN INITIAL EVALUATION

Date:
Dear
Your child, / , / has been referred for an evaluation to determine
(Student's Name) / (DOB)

eligibility for special education services. Federal and State regulations require that the school district obtain the written consent of parents before conducting such an evaluation.

A copy of the Procedural Safeguards in Special Education is enclosed.

A copy of the Procedural Safeguards in Special Education was provided to you previously this school year. If you would like another copy of the Procedural Safeguards, an explanation of these procedures, or if you have any questions, please contact:

at
(Name) / (Title) / (Telephone Number)

This document includes the following rights:

A. Parents have the right to refuse consent and, if given, it may be revoked at any time.

B. Parental failure to respond within 10 school days from the date of this notice shall be construed as refusal of consent.

C. If contested, your child's current educational placement will not change until due process proceedings have been completed.

D. Parents have the right to review and obtain copies of all records used as a basis for a referral.

E. Parents have the right to be fully informed of all evaluation results and to receive a copy of the evaluation report.

F. Parents have the right to obtain an independent evaluation as part of the evaluation process.

G. Parents have the right to utilize due process procedures.

The tests/evaluation procedures listed below were recommended

The PPT has decided that the available evaluation information listed below is sufficient to determine eligibility:

Reason: (specify)
TEST/EVALUATION PROCEDURE / AREA OF ASSESSMENT / EVALUATOR

Special adaptations or accommodations are to be considered when indicated by the student's language, cultural background or physical status. Adaptations/accommodations required for this evaluation are:

No adaptations/accommodations required

Adaptations/accommodations required: (specify)

PARENTAL CONSENT

I give my consent for the [DISTRICT NAME] Public Schools to utilize the evaluations described above. I understand that this consent may be revoked at any time.

Parent/Guardian Signature Date

I do not give my consent for the [DISTRICT NAME] Public Schools to conduct the evaluations described above. I understand that the school district must take steps as are necessary, which may include due process proceedings, to ensure that my child continues to receive a free appropriate public education.

Parent/Guardian Signature Date

ED625

January 2006